Inquest Jury Records Delays, Information-Sharing Failures and "Cavalier" Police Approach to Vulnerable Man (16 April 2026)

An inquest into the tragic death of EM at Queensway Underground Station in August 2023 has identified a series of failures by public authorities, including delays by Transport for London, gaps in critical information sharing, and what the jury described as a “cavalier attitude” by police officers towards a man in a mental health crisis.

The inquest examined not only the circumstances of EM’s death, but also the events in the days leading up to it, including police and ambulance attendance at his home as his mental health deteriorated.

Rachael Thacker, of Duncan Lewis Solicitors’ Actions Against Public Authorities team, instructed counsel Dr Anton Van Dellen, represented EM’s family throughout the proceedings.

After hearing extensive evidence, the jury concluded that a delay by TfL control in alerting the train driver to slow down or stop was probably causative of EM’s death.

In addition, the jury identified a number of omissions, which had been concerns of the family. These included failures to properly communicate that a warrant had been obtained under section 135 of the Mental Health Act 1983, and a lack of access to EM’s medical information, which meant key decisions were made without a full understanding of his condition. While the Coroner directed that these issues could not be formally recorded as causative, the jury found that they were important of note.

The jury was particularly critical of police conduct during a welfare visit the day before EM’s death. In a stark passage included in the Record of Inquest, they found:

“The Police’s visit to EM’s assisted living facility was cursory in nature… The haste with which they departed – having failed to take reasonable steps to check the status of the warrant – is a noteworthy omission, and indicative of a cavalier attitude to someone in a mental health crisis. A more detailed, measured and thoughtful assessment of EM’s situation was warranted.”

The inquest brought to the forefront several key questions, including; the process of obtaining a warrant under section 135 of the Mental Health Act 1983 (MHA) and the use of police powers under section 136 MHA in communal living areas.

In addition, the inquest raised questions as to what support our public services can offer a person who has become non-compliant with medication and, as such, increasingly vulnerable.

A recurring issue highlighted during the inquest was the lack of available mental health professionals on a Sunday afternoon. Evidence was heard about a new 24/7 community mental health centre introduced by South London and Maudsley NHS Foundation Trust, which has already shown promising results in reducing A&E admissions by providing immediate access to specialist care.

However, concerns remain that such services are not consistently available across the country, often depending on local funding. The inquest underscored the importance of ensuring that access to potentially life-saving mental health support is not determined by geography or timing.

For EM’s family, the jury’s findings – and the inclusion of these concerns in the official Record of Inquest – represent an important acknowledgment of the issues they have long raised.

They now await a decision from the Coroner on whether a Prevention of Future Deaths report will be issued, with the hope that lessons will be learned to prevent similar tragedies.

Supporting families through inquests

Duncan Lewis Solicitors’ Actions Against Public Authorities team has extensive experience supporting families through complex and often distressing inquest proceedings, particularly where there are concerns about state involvement or systemic failings.

If you have lost a loved one and need advice or support in relation to an inquest, our team is here to help. You can contact us via our website enquiry form or by calling 0333 772 0409.

About Rachael Thacker

Rachael Thacker is a Caseworker in the Actions Against Public Authorities team at Duncan Lewis Solicitors, based in Newcastle. She supports clients in complaints and civil claims against public bodies, including police forces, the Home Office, the Ministry of Justice, and local authorities.

Before joining the firm, Rachael volunteered with the organisation INQUEST, where she worked on projects and campaigns supporting bereaved families through the inquest process and monitoring developments in public policy.

Contact Rachael via email at rachaelt@duncanlewis.com or by telephone on 020 3114 1337.